10 Wall Street - Lower Level Norwalk, CT CLIENT INTAKE FORM. Parent(s) Name(s) : Address: Phone Numbers Mother Father.
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1 10 Wall Street - Lower Level Norwalk, CT CLIENT INTAKE FORM Parent(s) Name(s) : Address: Phone Numbers Mother Father Home: Work: Cell: Employer Name: Position: Employer Address: Employer Name: Position: Employer Address: How did you hear of this Office? Did anyone refer you? If so, may I have his/her name so that I may send a thank you? Child s Name: Nickname: Date of Birth: Age: Current Grade: School District: School Name: School Address: Special Education Director at District Level:
2 SpEd Administrator at School: Does your child have a 504 Plan? YES NO Does your child have an IEP? YES NO If so, under what eligibility category is the child classified on the IEP? CIRCLE ONE Autism Emotional Disturbance Multiple Disabilities Speech or Language Impaired Other Health Impaired Deaf-Blindness Hearing Impairment Orthopedic Impairment Traumatic Brain Injury OHI-ADD/ADHD Developmental Intellectual Disability Specific Learning Visual Impairment To Be Determined Delay (ages 3-5) Disability Do you believe this captures your child s disability? YES NO If no, please discuss what you believe his/her issues are. Does your child have multiple diagnoses? YES NO If yes, please elaborate here Is your child on any medications? YES NO Please elaborate here What do you think your child s level is in (below grade level, on grade level, above grade level) Reading: Writing: Math: Science/Reasoning: How does your child perform on standardized testing? (CMT s CAPT s, etc) (scores, test-taking, etc)
3 Please list Parental Concerns in the following areas: Reading Spelling Writing Handwriting Math Behavior Social Skills Friendships Emotions
4 Speech Language Transition Vocational Vision/Hearing Fine Motor Gross Motor Activities of Daily Living Extracurricular Activities/Leisure Skills Community Living
5 Other Concerns/Challenges Please list child s Strengths in the above areas: Was the school slow to acknowledge your child s special needs? Did you verbally or in writing ask them to evaluate your child? Did you pay to have your child evaluated privately? When was the last school evaluation done on your child? Has the school evaluated every three years? Did the school make available a copy of the evaluation report prior to the date of the PPT Meeting? Did you ever disagree with the school s evaluation and request an Independent Educational Evaluation at public expense? If so, how did the district respond? Did the school ever offer Extended School Year Services (ESY) to your child? Were those services appropriate to his/her needs? Do you see regression in your child during the summer whether ESY is offered or not?
6 Does your child receive an appropriate amount of Special Education teaching, Occupational, Speech and Language and or Physical Therapies to meet his/her needs? Why or why not? Does your child have behavior issues at school? Please explain. Do you believe these behaviors are tied to his/her disability? Was a Functional Behavior Assessment ever done? Has your child ever been restrained at school? Please describe the circumstances. Was your child ever sent home for behavior issues? If so, please explain the circumstances. Was your child ever suspended or expelled from school? When and why? Was a Manifestation Determination Hearing held? What was the outcome? Is your child ever teased or bullied at school? If so, please describe. Describe your child s current classroom/school. Note the number of children in the class, the type of classroom, the number of other children with disabilities, the number of teachers/aides. Does your child have a 1:1 aide? Is there an FM System, a sensory area, a break area, computers, etc?
7 In a perfect world, what would you want for your child in terms of school supports? What do you think your child needs in order to be successful at school? (Think in terms of teacher training, tutoring, direct instruction, ESY, private counseling, school counseling, assistive technology, OT, PT, Speech and Language Therapy, Typing classes, Social Skills, better communication, progress reports, aide support, modifications to school work, Applied Behavior Analysis, Positive Behavior Intervention Supports, etc) Have you ever retained an advocate or attorney before? If so, who? Have you ever filed a complaint with the CT State Department of Education? If so, what were the issues? Have you ever filed for due process or mediation with a district before? If so, what were the issues?
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